The Technique
Application-technique    |     Reduction of displaced fractures in MOKcast

The MOKcast technique is based on the stability principle of a closed cylinder, by the use of a Polyester cast with woven-in elastic thread ( DELTA CAST CONFORMABLE™ ), which change its properties with the number of layers applied.
This allows for the application of minimal, in the area of the fracture stable ( 3-5 layers ) and in the distal and proximal areas flexible ( 1-2 layers ) Cast.

Cast splints or split circular Cast?
In the last few years, Cast-splints have increasingly replaced the classic Plater-splint in the primary treatment. Many of them are prepadded, which makes the application quick, time-saving and clean. To achieve sufficient stability, those Cast-splints are mostly made of rigid cast ( Fibreglass 6-9 layers ), which greatly reduces their use in the primary treatment. They can not be used with accompanying massive soft-tissue swelling, or for the reduction of displayed fractures.
In comparison to a circular Cast, those Cast-splints give noticeably less support to a joint or fracture, especially the twisting movement, i.e. the rotation of the injured limb against a dorsal or volar splint, is very easily possible.
A Cast-splint has the same thickness and rigidity everywhere. This makes it unsuitable for a Focused Rigidity Cast.

A circular cast stabilises, through the principle of the closed cylinder, a fracture or a joint much better than a splint. On the other hand, a circular cast is often thought of as problematic in primary treatment. But this only applies to Fibreglass-cast, which by the way of their rigidity, their missing flexibility and their high memory effect (slip back in their original position) can often lead to problems for the patient.
By changing the rigid Fibreglass-cast for a semiflexible Polyester-cast with woven-in elastic thread (DELTA CAST CONFORMABLE™ ), the advantages of high fracture stability, through the closed cylinder principle, can be used from the first day of treatment. After splitting ( cutting with scissors), the Cast can be individually adapted to every degree of swelling. It is always adjustable and allows for measured compression of the surrounding soft-tissue. Through this, the principle of Sarmiento Fracture-Bracing can be used from the first day of treatment.

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The application of MOKcast is divided in 7 steps:

  1. The preparation of the material and positioning of the patient.
  2. Application of skin protection and, if needed, padding.
  3. Application of Delta Cast Conformable™ in the sense of FRC.
  4. Molding phase.
  5. Splitting and individual trim with bandage scissors.
  6. Re-application of the cast.
  7. Patient information.
  1. The preparation of the material and positioning of the patient:
    The materials should be pre-prepared to enable rapid application of the bandage. All the necessary materials should be placed within reach to avoid hold-ups in the procedure.
    The patient should be in a position which is comfortable to him/her and the person applying the bandage. This may vary depending on the extent of the injury, the diagnosis, the treatment method and the patient's condition.

  2. Application of skin protection and, if needed, padding:
    With MOKcast, the classic under cast padding is not necessary. Instead of the normal cast padding, which is often applied too thickly, a toweling tubular stockinet (DTN Terry Cloth Stockinet™) should be used, which adheres to the cast and does not need to be changed at eventual necessary cast checks. Exposed areas, i.e. fibula capitulum, can be additional padded by using U- or O- shaped adhesive Fleece.
    Padding as a "spacer" between the hard cast and the soft skin is not necessary any more, because in case the cast should feel to tight the cast itself can be loosened and adapted.
    Instead of the classic padding felt a special padding with elastic properties (Delta-rol S™) can be used, which works as a compression therapy against thrombosis like the elastic bandage of the lower leg. On top of this Delta-rol™, the reusable cast can be applied.

  3. Application of Delta Cast Conformable™ in the sense of FRC:
    A MOKcast can be applied by using different application techniques. The goal is to create a cast with different numbers of layers at different points of the cast. This can be achieved through simple circular bandaging or through the use of local cast strips.
    Other than the classic plaster, the MOKcast should be applied relatively tightly extending it by 50% to 70%. This achieve the best fit and bonding of layers.
    The number of layers varies in a MOKcast. In the area directly around the fracture a more rigid cast is created through the application of more layers. At the proximal and distal ends of the cast it stays more flexible through the use of less layers and so allows more active muscle function, if wanted.

    As a basic rule: The number of layers changes the properties of the cast.

    • 1st layer:  No sufficient fracture stability, high flexibility, optimal for soft edges.
    • 2nd layer:  Sufficient stability; cast is flexible.
    • 3rd layer:  Optimal stability; cast is flexible.
    • 4th layer:  Cast tens to rigid; reduced flexibility.
    • 5th layer  and more: Rigid cast; reduced or no flexibility.

    The decision if and where the cast should be rigid or flexible lies with the user.

    An absolutely exact application of the cast is not necessary, because even in dried condition the cast can be adjusted and allows an individual trim with bandage scissors.

  4. Molding phase:
    After application the cast gets molded to the patient's requirements for approximately four to six minutes.
    This optimize the fit and the bonding of layers. During the molding phase the position of the fracture ore the joint positions can be corrected if necessary.
    Any creases or folds in the cast can be smoothed out by pulling at the proximal and distal ends of the cast lengthwise.

  5. Splitting and individual trim with bandage scissors:
    The splitting of the MOKcast can be done with normal bandage scissors. The electric cast saw is not necessary any more.
    After the splitting the MOKcast loosens, through the working of the woven-in elastic thread, by itself. This is a special feature of Delta Cast Conformable™. If necessary, the cast can be loosened by bending it open.
    The individual trim with scissors can be done on the patient or, if possible, away from the patient.

  6. Re-application of the cast:
    The MOKcast can be adapted to the individual degree of swelling and than reapplied. Different methods can be uses to do this:
    • Re-application with a bandage:
      Cohesive, short stretch bandages (Delta-fix™) have been found to be reliable.
    • Re-application with Velcro-strips (DTN Hook & Loop™):
      This change the cast to a self-made, 100% fitting Brace and makes the removal and reapplication much easier.
    • Re-application with Sport-Tape-strips:
      This is an easy and quick method.

    The MOKcast can be taken off and be reapplied any number of times.
    This makes it possible, and easy, to check the skincondition, check wounds or apply physiotherapeutic treatment out of the cast.
    The MOKcast can be individually adapted at any time. It can be widened or, by cutting a cast strip away, even tightened.

  7. Patient information:
    The patient needs a detailed information about the cast. She/he should know, how to recognize possible complications and which measures he can take to prevent and treat him. The informed patient understands the principles of FRC and MOKcast quickly.
    She/he experience and enjoys a modern, patient orientated therapy and is positively motivated from the first day of treatment.
    The patient is the center of that treatment concept.
    The patient in plaster or in MOKcast is always right: Only someone actually wearing a cast can determine if the cast is comfortable or not. The ignoring of patient complains must be regarded as gravely negligent.

Reduction of displaced fractures in MOKcast.

The MOKcast technique shows special advantages in the reduction of displaced fractures.
Through the increase in the number of layers (ca. 7-9 layers) around the place of reduction, it is possible to stabilize displaced fractures in the optimal position for the healing process without creating a whole cast that is made out of a rigid, not adaptable, material. The real advantages of this technique is only apparent in the days following the reduction, because the MOKcast can be widened millimeter by millimeter if the patient feels it is too tight, something that can not be done with a plaster cast. This allows for fractionated loosening of the cast without putting the result of the reduction into jeopardy. After the swelling has gone down the MOKcast can be tightened again and so helps to avoid a slipping of the fracture through an optimally fitting cast.

Conservative treatment for an inoperable patient:
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  1. 1st X-ray after accident.
  2. Control X-ray in MOKcast after reduction.
  3. Control X-ray in MOKcast after 14 days.
Pre-operative reposition in MOKcast.
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  1. 1st X-ray after accident.
  2. Control X-ray pre-operative in MOKcast after reduction.
  3. Control X-ray post OP. The cast remains as a positioning splint.

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